Stress and Heart Attacks: The Lancet Lecture

Stress and Heart Attacks: The Lancet Lecture;
Prof. Sir Michael Marmot
Cardiology and Diabetes at the Limits, Cape Town, Feb 2011.

Opening the 2011 Cardiology and Diabetes at the Limits Congress in Cape Town, in a prime time lecture, Professor Sir Michael Marmot (UK) addressed the fact that in 2011 there are still huge global inequalities in health. These exist, as he pointed out, across continents and also within countries.

For example, in Glasgow (UK) male life expectancy in the poorest parts of the city is only 54 years. This is 8 years less life expectancy that the average man living in India where paradoxically causes of death are often poverty related! In the most affluent areas of Glasgow the average male life expectancy is almost 30 years longer at 82 years, however it is still the same “rich man’s diseases” that kill in any wealth bracket in Glasgow.

It is fairly obvious as Michael Marmot points out that there cannot be a biological or genetic explanation, as the causes of death are the same. It is simply the time taken to reach the end that differs, thus an alternative hypothesis needed to be sought. This led to the concept, as demonstrated in the Whitehall Studies, that other influence including psychosocial factors must have a significant role. Woody Allen’s quote “Man’s 2nd most interesting organ is his brain” was repeated!

The social gradient in health outcomes noted in Glasgow was also observed in the Whitehall study across all age groups studied. It would also seem that the USA may actually be in a worse overall position in terms of health outcomes than the UK despite a higher per capita spend on health.

At least some of these phenomena must surely relate to the observation via Meta-analysis that up to a 50% increased in CVD risk can be caused by changes in the “stress-control” loop. In this model a person who has a low level job, with bullying high demand management and little influence over these demands, is more stressed and more at risk of the effects of mental stress. Whereas a CEO, who has much more control and greater personal satisfaction rewards for overcoming challenges, will be less stressed and less likely to suffer the ill effects of stress (eg. alcohol, drugs etc).

In the Whitehall study, 1/3 of all mental health issues seemed to be related to this one issue of the stress-control system. However whilst this applies to men in the workplace, it seems that it is the household environment that may be more key in women based on the research presented.

Data were shown to suggest that the single influence of a fair working environment may affect a difference of up to 7 years of additional life expectancy, and perhaps more crucially a 17 year difference in disability free working life.
Data from primate studies were also presented showing that in monkeys the key influence on development of coronary artery plaques in non-ovarectomised females is whether or not the monkey is dominant or subordinate in the group. This would seem to support the psychosocial data in Whitehall.

In summing up, Sir Michael concluded that we do not only act as clinicians because of evidence. We also do what seems morally correct. Job stress, especially based around the principals of “locus of control” seems to have a major impact on health irrespective of personality type. Thus psychosocial factors, and especially issues around low self efficacy in the workplace/at home and low self esteem, seem to be a major challenge clinician’s face in the 21st century. There seems to be a merging of evidence with morality in this case.

In concluding Michael Marmot finished with:
“We need to create a world where social injustice is taken seriously”.